Minneapolis Veterans Affairs Medical Center, One Veterans Drive, Minneapolis, MN 55417, USA.
Ann Intern Med. 2013 Apr 2;158(7):535-43. doi: 10.7326/0003-4819-158-7-201304020-00005.
Optimum management to prevent recurrent kidney stones is uncertain.
To evaluate the benefits and harms of interventions to prevent recurrent kidney stones.
MEDLINE, Cochrane, and other databases through September 2012 and reference lists of systematic reviews and randomized, controlled trials (RCTs).
28 English-language RCTs that studied treatments to prevent recurrent kidney stones and reported stone outcomes.
One reviewer extracted data, a second checked accuracy, and 2 independently rated quality and graded strength of evidence.
In patients with 1 past calcium stone, low-strength evidence showed that increased fluid intake halved recurrent composite stone risk compared with no treatment (relative risk [RR], 0.45 [95% CI, 0.24 to 0.84]). Low-strength evidence showed that reducing soft-drink consumption decreased recurrent symptomatic stone risk (RR, 0.83 [CI, 0.71 to 0.98]). In patients with multiple past calcium stones, most of whom were receiving increased fluid intake, moderate-strength evidence showed that thiazides (RR, 0.52 [CI, 0.39 to 0.69]), citrates (RR, 0.25 [CI, 0.14 to 0.44]), and allopurinol (RR, 0.59 [CI, 0.42 to 0.84]) each further reduced composite stone recurrence risk compared with placebo or control, although the benefit from allopurinol seemed limited to patients with baseline hyperuricemia or hyperuricosuria. Other baseline biochemistry measures did not allow prediction of treatment efficacy. Low-strength evidence showed that neither citrate nor allopurinol combined with thiazide was superior to thiazide alone. There were few withdrawals among patients with increased fluid intake, many among those with other dietary interventions and more among those who received thiazide and citrate than among control patients. Reporting of adverse events was poor.
Most trial participants had idiopathic calcium stones. Nearly all studies reported a composite (including asymptomatic) stone recurrence outcome.
In patients with 1 past calcium stone, increased fluid intake reduced recurrence risk. In patients with multiple past calcium stones, addition of thiazide, citrate, or allopurinol further reduced risk.
Agency for Healthcare Research and Quality.
预防肾结石复发的最佳治疗方案仍不明确。
评估预防肾结石复发的干预措施的获益与危害。
通过 MEDLINE、Cochrane 及其他数据库检索 2012 年 9 月前的相关文献，并对系统评价和随机对照试验的参考文献进行检索。
28 篇评估预防肾结石复发的治疗方法并报告结石结局的英文随机对照试验。
1 名评价员提取数据，另 1 名评价员核对准确性，2 名评价员独立评价质量并对证据强度进行分级。
对于曾有 1 次钙结石的患者，低质量证据表明，与不治疗相比，增加液体摄入可使复合结石复发风险减半（相对危险度 [RR]，0.45 [95%CI，0.24 至 0.84]）。低质量证据表明，减少软饮料摄入可降低有症状结石复发风险（RR，0.83 [CI，0.71 至 0.98]）。对于曾有多次钙结石的患者，其中大多数正在接受增加液体摄入治疗，中等质量证据表明噻嗪类药物（RR，0.52 [CI，0.39 至 0.69]）、枸橼酸盐（RR，0.25 [CI，0.14 至 0.44]）和别嘌醇（RR，0.59 [CI，0.42 至 0.84]）与安慰剂或对照组相比，可进一步降低复合结石复发风险，尽管别嘌醇的获益似乎仅限于基线高尿酸血症或高尿酸尿症患者。其他基线生化指标不能预测治疗效果。低质量证据表明，枸橼酸盐或别嘌醇联合噻嗪类药物并不优于噻嗪类药物单药治疗。增加液体摄入的患者中，仅有少数人停药，而接受其他饮食干预的患者和接受噻嗪类药物与枸橼酸盐治疗的患者中，停药人数均多于对照组患者。不良事件报告情况较差。
大多数试验参与者患有特发性钙结石。几乎所有研究都报告了复合（包括无症状）结石复发结局。
对于曾有 1 次钙结石的患者，增加液体摄入可降低复发风险。对于曾有多次钙结石的患者，添加噻嗪类药物、枸橼酸盐或别嘌醇可进一步降低风险。
美国医疗保健研究与质量局。
